Stoneybrook Dental 15506 W. Stoneybrook Parkway, Suite 126,
Winter Garden, FL 34787 Phone: 407.877.0141 | Fax: 407.877.1633 |
Email: [email protected]
Dr. Wendi Wardlaw, DDS
Are you under a Physician’s care now? 〇
Yes 〇
No
If yes, please explain:
Have you ever been hospitalized or had a major operation? 〇 Yes
〇 No If yes, please explain:Have you ever had a serious head or
neck injury? 〇 Yes 〇 No If yes, please explain:
Are you taking any medications, pills, or drugs? 〇 Yes 〇 No If
yes, please explain:
Do you take, or have you taken, Phen-Fen or Redux? 〇 Yes 〇 No
Have you ever taken Fosamax, Boniva, Actonel or any
other medications containing bisphosphonates? 〇 Yes 〇 No
Are you on a special diet? 〇 Yes 〇 No Do you use tobacco? 〇 Yes
〇 No
Do you use controlled substances? 〇 Yes 〇 No WOMEN: Are you
Pregnant/Trying to get pregnant: 〇 Yes 〇 No Taking Oral
Contraceptives? 〇 Yes 〇 No Nursing? 〇 Yes 〇 No
Are you allergic to any of the following: Aspirin Penicillin
Codeine Local Anesthestics Acrylic Metal Latex Sulfa Drugs Other If
yes, please explain:
Do you have, or have you had, any of the following?
Have you ever had any serious illness not listed above? 〇 Yes 〇
No Comments:
AIDS/HIV Positive Alzheimer’s Disease Anaphylaxis Anemia Angina
Arthritis/Gout Artificial Heart Valve Artificial Joint Asthma Blood
Disease Blood Transfusion Breathing Problem Bruise Easily Cancer
Chemotherapy Chest Pains Cold Sores/Fever Blisters Congential Heart
Disorder Convulsions
〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇
No 〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇
No 〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇
No 〇 Yes 〇 No
Cortisone Medicine Diabetes Drug Addiction Easily Winded
Emphysema Epilepsy or Seizures Excessive Bleeding Excessive Thirst
Fainting Spells/Dizziness Frequent Cough Frequent Diarrhea Frequent
Headaches Genital Herpes Glaucoma Hay Fever Heart Attack/Failure
Heart Murmur Heart Pacemaker Heart Trouble/Disease
〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇
No 〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇
No 〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇
No 〇 Yes 〇 No
Hemophilia Hepatitis A Hepatitis B or C Herpes High Blood
Pressure High Cholesterol Hives or Rash Hypoglycemia Irregular
Heartbeat Kidney Problems Leukemia Liver Disease Low Blood Pressure
Lung Disease Mitral Valve Prolapse Osteoporosis Pain in Jaw Joints
Parathyroid Disease Psychiatric Care
〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇
No 〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇
No 〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇
No 〇 Yes 〇 No
Radiation Treatments Recent Weight Loss Renal Dialysis Rheumatic
Fever Rheumatism Scarlet Fever Shingles Sickle Cell Disease Sinus
Trouble Spina Bifida Stomach/Intestinal Disease Stroke Swelling of
Limbs Thyroid Disease Tonsillitis Tuberculosis Tumors or Growths
Ulcers Venereal Disease Yellow Jaundice
〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇
No 〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇
No 〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇 No 〇 Yes 〇
No 〇 Yes 〇 No 〇 Yes 〇 No
MEDICAL HISTORYPATIENT NAME: BIRTH DATE:
Although dental personnel primarily treat the area in and around
your mouth, your mouth is a part of your entire body. Health
problems that you may have, or medication that you may be taking,
could have an important relationship with the dentistry you will
receive. Thank you for answering the following questions.
To the best of my knowledge, the questions on this form have
been accurately answered. I understand that providing incorrect
information can be dangerous to my (or patient’s) health. It is my
responsibility to inform the Dental Office of any changes in
medical status.
SIGNATURE OF PATIENT, PARENT or GUARDIAN DATE
If yes please explain: No If yes please explain: No If yes
please explain1: If yes please explain1: No: Aspirin Penicillin
Codeine Local Anesthestics Acrylic Sulfa Drugs Other If yes please
explain: No1: Comments: NoComments: PATIENT NAME: BIRTH DATE:
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